1. Cardiopulmonary ressuscitation Dr Guillaume Thiery, Medical ICU Klinicki Centar Univerziteta Sarajevo St Louis Hospita, Paris

2. Out-of-hospital cardiopulmonary arrest by aetiology

4. Importance of each link Stiell et al. NEJM, 2004

8. Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?"

9. Discharged alive: Compression + mouth to mouth29/278 (10,4%) Compression alone35/240 (14,6%)

10. Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Cardio Pulmonary Ressuscitation

11. Cardio Cerebral Ressuscitation Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Cardio Pulmonary Ressuscitation

12. 2006 Overall survival increased from 19% to 57% Survival neurologically intact increased from 15% to 48%

13. 2009 Overall survival increased from 22% to 44% 88% of these survivors were discharged with good neurological outcome

14. Cardio Cerebral Ressuscitation Reduce or avoid positive pressure ventilation, Airway management is limited to a pharyngal devince (airway) and O2 supplementation, Avoid or delay intubation (3 cycles of 2 min) No more than 10 sec without compression,

15. 3 rules of airway management Head tilt (hyperextention) and chin lift Pharyngeal device (airway) O2 non mask with reserve 15 L/min

16. 3 rules of airway management Head tilt (hyperextention) and chin lift Pharyngeal device (airway) O2 non mask with reserve 15 L/min

17. 3 rules of airway management Head tilt (hyperextention) and chin lift Pharyngeal device (airway) O2 non mask with reserve 15 L/min

18. 2004

19. Deleterious effect of hyperventilation Mean Intrathoracic pressure Coronary Perfusion Pressure

20. The 4th rule of airway management If Positive Pressure Ventilation, by mask of intubation:  Maximun 12/min

21. Cardio Cerebral Ressuscitation ALL TO IMPROVE COMPRESSIONS Mandatory pre-shock compression during 2 min, 100 compressions/minute, 2 min of compression after each shock before pulse check No more than 10 sec without compression, Reduce or avoid positive pressure ventilation, Airway management is limited to a pharyngal device (airway) and O2 supplementation, Avoid or delay intubation (3 cycles of 2 min), When intubated, maximun resp frequency 12/min.

22. Clincal case Patients 45 years old presents in the ER for chest pain 10 after arrival, – Acute chest pain – Unresponsive

23. What would you do first? Chest compressions 100/min Mask ventilation 12/min + oxygen Rapid intubation Rapid defibrillation – Maximum joules – One time – Resume ventilation and compressions during 2 min +/- drugs: adrenalin Check pulse after 2 min of compressions/ventilation New defibrillation after 2 min if not Return of Spontaneous Circulation.

24. What could have been done differently? Chest compressions 100/min Mask ventilation 12/min + oxygen Rapid intubation Rapid defibrillation – Maximum joules – One time – Resume ventilation and compressions during 2 min +/- drugs: adrenalin Check pulse after 2 min of compressions/ventilation New defibrillation after 2 min if not Return of Spontaneous Circulation. Etc…

25. What could have been done differently? Chest compressions 100/min Head tilt and Chin lift Pharyngeal device (airway) placement Oxygen mask 15L/min Rapid defibrillation – Maximum joules – One time – Resume ventilation and compressions during 2 min +/- drugs: adrenalin Check pulse after 2 min of compressions/ventilation New defibrillation after 2 min if not Return of Spontaneous Circulation.

26. Case (suite) Patients gets return to spontaneous circulation But remains unconscious

27. Case (suite) If the patient has this ECG

28. Therapeutic hypothermia Goal: temp 32 – 34°C during 12 to 18h after return of spontaneous circulation, External cooling: –Axillar and Femoral ice –Blowing cold air Internal cooling: –Infusion of 30 ml/kg of cold NaCl 4°C

29. Therapeutic hypothermia

31. Experience in the medical ICU in KCU Sarajevo (Jedinica Internisticke Intenzivne Terapije) 5 patients admitted in the ICU for cardiac arrest remaining unconscious after successfull ressuscitation VT/VF initial or after adrenalin All myocardial infarction Mean age 59

32. MedianMin-max Time from end CPR to temp < 36°C 6,2h0 – 7h Time < 36°C55 – 20h Time < 34°C50 – 17h Nadir temperature33,2°C32,5° - 35°C Characteristic of the hypothermia

33. MedianMin-max Minium glycemia5,54,4 – 15,8 Maximum glycemia10,77,2 – 27,7 Mininum K32,5 – 4,6 Maximum K4,63,7 – 6,4 CK24001300 - 11300 Complications

34. Shock state2/5 ARDS1/5 DIC1/5 Acute renal failure2/5 Seizures of myoclonies2/5 Complications

35. Survival4/5 Neurological intact3/5 Duration of MVMedian 8 days (min 1 - max 40) Lenght of stay in the ICUMedial 14 dayx (min 1 – max 47) Outcome